UNIVERSITY HEALTH CARE ADVANTAGE (HMO) 2015 FORMULARY (LIST OF COVERED DRUGS)

Transcription

1 UNIVERSITY HEALTH CARE ADVANTAGE (HMO) 2015 FORMULARY (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN , 16 This formulary was updated on 10/15/2015. For more recent information or other questions, please contact University Health Care Advantage Member Services at or, for TTY users, Toll-free 711, Monday through Sunday from 8:00 a.m. to 8:00 p.m. (Pacific Standard Time), or visit University Health Care Advantage is an HMO plan with a Medicare contract. Enrollment in University Health Care Advantage depends on contract renewal. This information is available for free in other languages. Please contact our Member Services at for additional information. TTY users should call 711. Hours are: 8:00 a.m. until 8:00 p.m., Pacific Standard Time, 7 days a week. Member Services also has free language interpreter services available for non-english speakers. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro número de servicio al cliente , 8:00 a.m. a 8:00 p.m., hora estándar del pacífico, siete días a la semana. Los usuarios de TTY deben llamar al 711. Thông tin này có sẵn miễn phí bằng các ngôn ngữ khác. Xin vui lòng gọi Dịch Vụ Hội Viên của chúng tôi tại số , 8:00 sáng đến 8:00 chiều, giờ Chuẩn Thái Bình Dương, 7 ngày một tuần. Người dùng TTY gọi số 點至晚上 8 點之間致電我們的會員服務號碼 , 時間為太平洋標準時間 TTY 使用者請撥打 711 H2986_PD_201, Complete Formulary Page 1

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means University Health Care Advantage. When it refers to plan or our plan, it means University Health Care Advantage (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of November 01, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. H2986_PD_201, Complete Formulary Page 2

3 What is the University Health Care Advantage (HMO) Formulary? A formulary is a list of covered drugs selected by University Health Care Advantage (HMO) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. University Health Care Advantage (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a University Health Care Advantage (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as November 01, To get updated information about the drugs covered by University Health Care Advantage (HMO), please contact us. Our contact information appears on the front and back cover pages. In the event we make a non-maintance change to the formulary, we will post an errata sheet to our Web site and mail a letter to members. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 14. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 14. Then look under the category name for your drug. H2986_PD_201, Complete Formulary Page 3

4 Alphabetical ing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? University Health Care Advantage (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: University Health Care Advantage (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from University Health Care Advantage (HMO) before you fill your prescriptions. If you don t get approval, University Health Care Advantage (HMO) may not cover the drug. Quantity Limits: For certain drugs, University Health Care Advantage (HMO) limits the amount of the drug that our plan will cover. For example, University Health Care Advantage (HMO) provides 30 pills per prescription for Ambien. This may be in addition to a standard one-month or threemonth supply. Step Therapy: In some cases, University Health Care Advantage (HMO) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, University Health Care Advantage (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 14. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask University Health Care Advantage (HMO) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the University Health Care Advantage (HMO) formulary? on page 5 (below) for information about how to request an exception. H2986_PD_201, Complete Formulary Page 4

5 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that University Health Care Advantage (HMO) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by University Health Care Advantage (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask University Health Care Advantage (HMO) to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the University Health Care Advantage (HMO) s Formulary? You can ask University Health Care Advantage (HMO) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs University Health Care Advantage (HMO) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, University Health Care Advantage (HMO) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. H2986_PD_201, Complete Formulary Page 5

6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least a 91 and may be up to a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. In circumstances where a member is changing from one treatment setting to another, University Health Care Advantage (HMO) will ensure a transition process for approving non-formulary Part D drugs. This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes include: members who are discharged from a hospital to a home; members who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary; members who end a long-term care facility stay and return to the community; and, members who are discharged from psychiatric hospitals with medication regimens that are highly individualized. The pharmacy benefit manager for University Health Care Advantage (HMO) will provide pharmacies with access to representatives of the plan who have the ability to override pharmacy claims processing issues. This access will allow pharmacies to obtain prescription claims overrides at the point-of-sale and ensure that members receive reliable access to medications. H2986_PD_201, Complete Formulary Page 6

7 For more information For more detailed information about your University Health Care Advantage (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about University Health Care Advantage (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit H2986_PD_201, Complete Formulary Page 7

8 University Health Care Advantage (HMO) s Formulary The formulary beginning on Formulary Page 14 provides coverage information about the drugs covered by University Health Care Advantage (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on Index Page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AVINZA) and generic drugs are listed in lower-case italics (e.g., acetaminophen). The information in the Requirements/Limits column tells you if University Health Care Advantage (HMO) has any special requirements for coverage of your drug. The second column of the chart lists the drug tier. Every drug on the plan s Drug is in one of six costsharing tiers. The tables below provide an explanation of each tier. Network Retail Pharmacy Drug Tier Copayment Levels Tier Copay for up to a Copay for up to a one-month supply three-month supply Tier 1 (Preferred Generic) $2 $6 Tier 2 (NON-Preferred Generic) $15 $45 Tier 3 (Preferred Brand) $45 $135 Tier 4 (NON-Preferred Brand Name) $95 $285 Tier 5 (Specialty) 33% of cost 33% of cost Tier 6 (Select Diabetic Drugs) $2 $6 Network Mail Order Drug Tier Copayment Levels Tier Copay for up to a Copay for up to a one-month supply three-month supply Tier 1 (Preferred Generic) $2 $4 Tier 2 (NON-Preferred Generic) $15 $30 Tier 3 (Preferred Brand) $45 $90 Tier 4 (NON-Preferred Brand Name) $95 $190 Tier 5 (Specialty) 33% of cost 33% of cost Tier 6 (Select Diabetic Drugs) $2 $4 H2986_PD_201, Complete Formulary Page 8

9 The following coverage abbreviations appear in the Requirements/Limits column. COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD PA-HRM PA NSO QL ST Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from University Health Care Advantage (HMO) before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from University Health Care Advantage (HMO) to determine whether this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 years or older are required to get prior authorization from University Health Care Advantage (HMO) before filling your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. If you are a new member or if you have not taken this drug previously, you (or your physician) are required to get prior authorization from University Health Care Advantage (HMO) before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. University Health Care Advantage (HMO) limits the amount of this drug that is covered per prescription, or within a specific time frame. Before University Health Care Advantage (HMO) will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. H2986_PD_201, Complete Formulary Page 9

10 OTHER COVERAGE ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION LA Limited Access Drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at number at , 8:00 a.m. to 8:00 p.m., Pacific Standard Time, 7 days a week. TTY users call 711. GC Gap Coverage We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 12h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 12h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad DESCRIPTION adhesive patch aerosol, breath activated aerosol, powder aerosol powder, breath activated aerosol refill aerosol with adapter Ampule bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 12 hour extended release capsule, 24 hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, 24 hour sustained action capsule, 12 hour sustained release capsule, 24 hour sustained release capsule, 24 hour controlled-onset pellets capsule, 24 hour sustained release pellets capsule, sprinkle capsule sustained release pellets capsule with device capsule, delayed release capsule, extended release capsule, sustained action combination: capsule, pad combination: ointment, foam combination: ointment, lotion combination: tablet, pad H2986_PD_201, Complete Formulary Page 10

11 ABBREVIATION DESCRIPTION combo. pkg combination package cpmp 12hr capsule, 12 hour multiphasic cpmp 24hr capsule, 24 hour multiphasic cpmp capsule, multiphasic, 30%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(2-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback g Gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution iv soln. intravenous solution jel Jelly jelly/app jelly with applicator jel/pf app jelly with pre-filled applicator kit cl&crm kit: cleanser and cream kt crm le kit: cream, lotion emollient kt lotn ce kit: lotion, cream emollient kt oint le kit: ointment, lotion emollient lotion, er lotion, extended release lozenge hd lozenge handle H2986_PD_201, Complete Formulary Page 11

12 ABBREVIATION m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 12h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon DESCRIPTION medicated heated patch mucoadhesive buccal tablet Microgram medicated pad medicated swab medicated tape Milligram Milliliter mucoadhesive system, 12 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal Suppository suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted H2986_PD_201, Complete Formulary Page 12

13 ABBREVIATION syringekit tab chew tab er 12h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 12h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 12hr tbmp 24hr u vag ring DESCRIPTION syringe kit tablet, chewable tablet, 12 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 12 hour sustained release tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 12 hour multiphasic tablet, 24 hour multiphasic unit vaginal ring H2986_PD_201, Complete Formulary Page 13

14 Analgesics Analgesics, Miscellaneous ABSTRAL SUBLINGUAL TABLET 100 MCG ABSTRAL SUBLINGUAL TABLET 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG 4 PA; QL (120 per 30 5 PA; QL (120 per 30 acetaminophen-codeine oral solution (Acetaminophen with Codeine) ; QL (2700 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine ; QL (360 per 30 mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine ; QL (180 per 30 mg No.3) ACTIQ 5 PA; QL (120 per 30 AVINZA ORAL CAPSULE, ER 4 ST; QL (30 per 30 MULTIPHASE 24 HR 120 MG, 30 MG, 45 MG, 60 MG, 75 MG AVINZA ORAL CAPSULE, ER 4 ST; QL (60 per 30 MULTIPHASE 24 HR 90 MG BUPRENEX 4 buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral capsule mg (Esgic) 2 PA-HRM; GC; QL (180 per 30 butalb-acetaminophen-caffeine oral solution mg/15 ml (Butalb/Acetaminophe n/caffeine) 2 PA-HRM; GC; QL (2700 per 30 butalbital-acetaminop-caf-cod (Fioricet with Codeine) 2 PA-HRM; GC; QL (180 per 30 butalbital-acetaminophen (Tencon) 2 PA-HRM; GC; QL (180 per 30 butalbital-acetaminophen-caff oral tablet mg (Esgic) 2 PA-HRM; GC; QL (180 per 30 butalbital-aspirin-caffeine oral capsule (Fiorinal) 2 PA-HRM; GC; QL (180 per 30 butorphanol tartrate injection (Butorphanol Tartrate) butorphanol tartrate nasal (Butorphanol Tartrate) ; QL (5 per 28 14

15 BUTRANS 3 QL (4 per 28 CAPITAL WITH CODEINE 4 QL (2700 per 30 codeine sulfate oral solution 15 mg/2.5 ml (Codeine Sulfate) 4 QL (1800 per 30 (2.5 ml) codeine sulfate oral tablet (Codeine Sulfate) ; QL (180 per 30 codeine-butalbital-asa-caffein oral capsule mg (Fiorinal with Codeine #3) 2 PA-HRM; GC; QL (180 per 30 CONZIP 4 QL (30 per 30 DEMEROL (PF) INJECTION 4 SOLUTION DEMEROL (PF) INJECTION 4 SYRINGE DEMEROL INJECTION SOLUTION 4 DEMEROL ORAL 4 QL (180 per 30 DHCODEINE 4 QL (300 per 30 BT-ACETAMINOPHN-CAFF ORAL CAPSULE MG dihydrocode-acetaminophen-caff oral capsule (Trezix) ; QL (300 per 30 dihydrocodeine-aspirin-caff (Synalgos-Dc) ; QL (360 per 30 DILAUDID (PF) 4 DILAUDID ORAL LIQUID 4 QL (1200 per 30 DILAUDID ORAL TABLET 2 MG, 4 4 QL (180 per 30 MG DILAUDID ORAL TABLET 8 MG 4 QL (240 per 30 DILAUDID-HP (PF) INJECTION 4 DISKETS 4 QL (90 per 30 DOLOPHINE ORAL 4 QL (360 per 30 DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR 4 PA; QL (20 per 30 DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 4 PA; QL (10 per 30 MCG/HR, 50 MCG/HR, 75 MCG/HR DURAMORPH (PF) 4 15

16 EMBEDA ORAL CAPSULE,ORAL 4 QL (120 per 30 ONLY,EXT.REL PELL MG, MG EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 30 ONLY,EXT.REL PELL MG, MG, 50-2 MG, MG ESGIC 4 PA-HRM; QL (180 per 30 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 16 MG, 8 MG EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 32 MG 4 PA; QL (30 per 30 4 PA; QL (60 per 30 fentanyl citrate (Actiq) 5 PA; QL (120 per 30 fentanyl transdermal patch 72 hour 100 mcg/hr (Duragesic) 2 PA; GC; QL (20 per 30 fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 (Duragesic) 2 PA; GC; QL (10 per 30 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour FENTORA 5 PA; QL (120 per 30 FIORICET WITH CODEINE ORAL CAPSULE MG 4 PA-HRM; QL (180 per 30 FIORINAL 4 PA-HRM; QL (180 per 30 FIORINAL-CODEINE #3 4 PA-HRM; QL (180 per 30 HYCET 4 QL (2700 per 30 hydrocodone-acetaminophen oral solution (Hycet) ; QL (2700 per 30 hydrocodone-acetaminophen oral tablet mg, mg, mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 16

17 hydrocodone-acetaminophen oral tablet mg, mg, mg, mg (Norco) ; QL (360 per 30 hydrocodone-ibuprofen (Ibudone) ; QL (150 per 30 hydromorphone (pf) injection solution 10 (Hydromorphone mg/ml HCl/PF) hydromorphone (pf) injection solution 4 (Dilaudid) mg/ml hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid (Dilaudid) ; QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) ; QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) ; QL (240 per 30 hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg (Exalgo) 2 PA; GC; QL (30 per 30 hydromorphone oral tablet extended release 24 hr 32 mg (Exalgo) 2 PA; GC; QL (60 per 30 HYSINGLA ER 4 PA; QL (30 per 30 IBUDONE 4 QL (150 per 30 ibuprofen-oxycodone (Ibuprofen/Oxycodone HCl) ; QL (28 per 30 INFUMORPH P/F 4 KADIAN ORAL 4 ST; QL (60 per 30 CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG, 80 MG KADIAN ORAL 5 ST; QL (60 per 30 CAPSULE,EXTEND.RELEASE PELLETS 100 MG, 130 MG, 150 MG KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG 5 ST; QL (120 per 30 17

18 LAZANDA 5 PA; QL (30 per 30 levorphanol tartrate (Levorphanol Tartrate) ; QL (180 per 30 LORTAB QL (360 per 30 LORTAB QL (360 per 30 LORTAB QL (360 per 30 LORTAB ELIXIR ORAL SOLUTION 4 QL (2025 per MG/15 ML meperidine (pf) (Meperidine HCl/PF) meperidine injection cartridge (Meperidine HCl) meperidine oral solution (Meperidine HCl) ; QL (900 per 30 meperidine oral tablet (Demerol) ; QL (180 per 30 methadone hcl oral concentrate 10 mg/ml (Methadose) ; QL (1800 per 30 METHADONE HCL ORAL CONCENTRATE 10 MG/ML 4 QL (1800 per 30 methadone hcl oral tablet,soluble 40 mg (Diskets) ; QL (90 per 30 methadone injection (Methadone HCl) methadone oral (Methadone HCl) ; QL (1800 per 30 methadone oral (Dolophine HCl) ; QL (360 per 30 morphine (pf) injection solution (Morphine Sulfate/PF) morphine (pf) intravenous (Morphine Sulfate/PF) morphine concentrate oral solution (Msir) ; QL (200 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 15 mg/ml, 8 (Morphine Sulfate) mg/ml morphine injection syringe 10 mg/ml, 2 (Morphine Sulfate) mg/ml morphine intramuscular (Morphine Sulfate) 18

19 morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, (Morphine Sulfate) 50 mg/ml morphine intravenous (Morphine Sulfate) morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg (Avinza) 2 ST; GC; QL (30 per 30 morphine oral capsule, er multiphase 24 hr 90 mg (Avinza) 2 ST; GC; QL (60 per 30 morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 (Kadian) 2 ST; GC; QL (60 per 30 mg, 80 mg morphine oral capsule,extend.release (Kadian) 5 ST; QL (60 per 30 pellets 100 mg morphine oral solution 10 mg/5 ml (Msir) ; QL (700 per 30 morphine oral solution 20 mg/5 ml (Msir) ; QL (300 per 30 MORPHINE ORAL TABLET ; QL (180 per 30 morphine oral tablet extended release 100 (MS Contin) ; QL (120 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 200 mg (MS Contin) ; QL (180 per 30 morphine rectal (Morphine Sulfate) morphine sulfate-pf (Morphine Sulfate/PF) MS CONTIN ORAL TABLET 4 QL (120 per 30 EXTENDED RELEASE 100 MG, 30 MG, 60 MG MS CONTIN ORAL TABLET 4 QL (180 per 30 EXTENDED RELEASE 15 MG, 200 MG nalbuphine injection (Nalbuphine HCl) NORCO 4 QL (360 per 30 NUCYNTA 3 QL (181 per 30 NUCYNTA ER 3 QL (60 per 30 OFIRMEV 4 19

20 OPANA ER ORAL TABLET,ORAL 4 QL (60 per 30 ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 5 MG, 7.5 MG OPANA ER ORAL TABLET,ORAL 4 QL (120 per 30 ONLY,EXT.REL.12 HR 30 MG, 40 MG OPANA INJECTION 4 OPANA ORAL 4 QL (180 per 30 OXECTA ORAL TABLET, ORAL 4 QL (540 per 30 ONLY 5 MG OXECTA ORAL TABLET, ORAL 4 QL (360 per 30 ONLY 7.5 MG oxycodone hcl-acetaminophen oral solution mg/5 ml (Oxycodone HCl/Acetaminophen) ; QL (1800 per 30 oxycodone hcl-acetaminophen oral tablet mg, mg, mg, mg (Percocet) ; QL (360 per 30 oxycodone hcl-aspirin (Percodan) ; QL (360 per 30 oxycodone oral capsule (Oxycodone HCl) ; QL (180 per 30 oxycodone oral concentrate (Oxycodone HCl) ; QL (180 per 30 oxycodone oral solution (Oxycodone HCl) ; QL (1300 per 30 oxycodone oral tablet (Roxicodone) ; QL (180 per 30 oxycodone oral tablet,oral only,ext.rel.12 (Oxycodone HCl) 4 QL (60 per 30 hr 10 mg, 20 mg, 40 mg oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg (Oxycodone HCl) 4 QL (120 per 30 oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-acetaminophen oral tablet mg (Percocet) ; QL (360 per 30 (Percocet) ; QL (180 per 30 20

21 oxycodone-acetaminophen oral tablet mg (Percocet) ; QL (240 per 30 oxycodone-aspirin (Percodan) ; QL (360 per 30 OXYCONTIN ORAL 3 QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL 3 QL (120 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) ; QL (180 per 30 oxymorphone oral tablet extended release (Opana ER) ; QL (60 per hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) ; QL (120 per hr 30 mg, 40 mg pentazocine-naloxone (Pentazocine HCl/Naloxone HCl) ; QL (360 per 30 PERCOCET ORAL TABLET QL (360 per 30 MG, MG, MG, MG PERCODAN 4 QL (360 per 30 PRIMLEV 4 QL (390 per 30 ROXICODONE 4 QL (180 per 30 SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 5 PA; QL (120 per 30 SYNALGOS-DC 4 QL (360 per 30 TALWIN 4 tramadol oral capsule,er biphase 24 hr (Conzip) ; QL (30 per 30 tramadol oral capsule,er biphase 24 hr (Conzip) ; QL (30 per 30 tramadol oral tablet (Ultram) ; QL (240 per 30 tramadol oral tablet extended release 24 hr 100 mg (Ultram ER) ; QL (90 per 30 21

22 tramadol oral tablet extended release 24 hr 200 mg, 300 mg (Ultram ER) ; QL (30 per 30 tramadol oral tablet, er multiphase 24 hr (Ultram ER) ; QL (30 per 30 tramadol-acetaminophen (Ultracet) ; QL (240 per 30 TYLENOL-CODEINE #3 4 QL (360 per 30 TYLENOL-CODEINE #4 4 QL (180 per 30 ULTRACET 4 QL (240 per 30 ULTRAM 4 QL (240 per 30 ULTRAM ER ORAL TABLET 4 QL (90 per 30 EXTENDED RELEASE 24 HR 100 MG ULTRAM ER ORAL TABLET 4 QL (30 per 30 EXTENDED RELEASE 24 HR 200 MG, 300 MG VERDROCET 4 QL (360 per 30 VICOPROFEN 4 QL (150 per 30 XARTEMIS XR 3 QL (360 per 30 XODOL 10/300 4 QL (390 per 30 XODOL 5/300 4 QL (390 per 30 XODOL 7.5/300 4 QL (390 per 30 xylon 10 (Ibudone) ; QL (150 per 30 ZAMICET 4 QL (2700 per 30 ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR Nonsteroidal Anti-Inflammatory Agents ANAPROX 4 ANAPROX DS 4 ARTHROTEC 50 4 ARTHROTEC 75 4 CALDOLOR INTRAVENOUS 4 RECON SOLN CAMBIA 4 CATAFLAM 4 4 PA; QL (60 per 30 22

23 CELEBREX 4 QL (60 per 30 celecoxib (Celebrex) ; QL (60 per 30 choline,magnesium salicylate (Choline Sal/Mag Salicylate) COMFORT PAC-IBUPROFEN 1 GC COMFORT PAC-MELOXICAM 1 GC COMFORT PAC-NAPROXEN 1 GC DAYPRO 4 diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical drops (Pennsaid) diclofenac sodium topical gel (Solaraze) 5 diclofenac-misoprostol (Arthrotec 75) diflunisal (Diflunisal) DUEXIS 4 QL (90 per 30 DYLOJECT 4 QL (120 per 30 EC-NAPROSYN 4 etodolac (Etodolac) FELDENE 4 FENOPROFEN ORAL CAPSULE 4 fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR 3 PA flurbiprofen (Ansaid) ibuprofen oral (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, (Ibuprofen) 1 GC 800 mg INDOCIN INTRAVENOUS 4 PA-HRM INDOCIN ORAL 4 PA-HRM INDOCIN RECTAL 4 indomethacin oral capsule 25 mg (Indomethacin) 2 PA-HRM; GC; QL (240 per 30 23

24 indomethacin oral capsule 50 mg (Indomethacin) 2 PA-HRM; GC; QL (120 per 30 indomethacin oral capsule, extended release (Indomethacin) 2 PA-HRM; GC; QL (60 per 30 indomethacin sodium (Indocin I.V.) 2 PA-HRM; GC ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) hr 200 mg ketorolac injection cartridge 15 mg/ml (Toradol) ; QL (40 per 30 ketorolac injection cartridge 30 mg/ml (Toradol) ; QL (20 per 30 ketorolac injection solution 15 mg/ml (Ketorolac Tromethamine) ; QL (40 per 30 ketorolac injection solution 30 mg/ml (1 ml) (Ketorolac Tromethamine) ; QL (20 per 30 ketorolac intramuscular solution (Ketorolac Tromethamine) ; QL (20 per 30 ketorolac oral (Ketorolac Tromethamine) ; QL (20 per 30 meclofenamate oral (Meclofenamate Sodium) mefenamic acid (Ponstel) meloxicam oral suspension (Mobic) meloxicam oral tablet (Mobic) 1 GC MOBIC 4 nabumetone (Nabumetone) NALFON ORAL CAPSULE 400 MG 4 NAPROSYN 4 naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) 1 GC naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg (Anaprox Ds) 1 GC 24

25 naproxen sodium oral tablet, er multiphase 24 hr NEOPROFEN (IBUPROFEN LYSN)(PF) Drug Name (Naprelan) oxaprozin (Daypro) PENNSAID 4 piroxicam (Feldene) PONSTEL 4 salsalate (Salsalate) SOLARAZE 5 SPRIX 4 QL (25 per 30 sulindac oral (Sulindac) TIVORBEX 4 PA-HRM; QL (90 per 30 tolmetin (Tolmetin Sodium) VIMOVO 4 VOLTAREN TOPICAL 3 VOLTAREN-XR 4 ZIPSOR 4 ZORVOLEX 4 Anesthetics Local Anesthetics cocaine topical solution 4 % (Cocaine HCl) EMLA 4 PA BvD; (PA for ESRD Only) glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) 2 PA BvD; (PA for ESRD Only); GC (Lidocaine HCl/PF) lidocaine (pf) intravenous syringe 100 mg/5 ml (2%) lidocaine hcl injection solution (Xylocaine) 2 PA BvD; (PA for ESRD Only); GC lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) 4 25

26 lidocaine hcl mucous membrane jelly in (Lidocaine HCl) applicator lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) LIDOCAINE HCL-PF INJECTION SOLUTION 10 MG/ML (1 %), 15 4 PA BvD; (PA for ESRD Only) MG/ML (1.5 %), 40 MG/ML (4 %) lidocaine topical adhesive (Lidoderm) 2 PA; GC patch,medicated lidocaine topical ointment (Lidocaine) 2 PA BvD; (PA for ESRD Only); GC lidocaine-prilocaine topical (EMLA) 2 PA BvD; (PA for ESRD Only); GC lidocaine-prilocaine topical kit (Relador Pak) 2 PA BvD; GC lidocaine-tetracaine (Pliaglis) 2 PA BvD; GC LIDODERM 4 PA PLIAGLIS 4 PA BvD; (PA for ESRD Only) PONTOCAINE TOPICAL SOLUTION 4 PA BvD; (PA for ESRD Only) RELADOR PAK 2 PA BvD; GC SYNERA 4 PA BvD; (PA for ESRD Only) XYLOCAINE INJECTION 4 SOLUTION XYLOCAINE INJECTION SOLUTION 4 PA BvD; (PA for ESRD Only) XYLOCAINE MUCOUS MEMBRANE SOLUTION 4 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) ANTABUSE 4 BUNAVAIL 4 PA; QL (60 per 30 26

27 buprenorphine hcl sublingual (Subutex) 2 PA; GC; QL (90 per 30 buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) 2 PA; GC; QL (90 per 30 bupropion hcl sr 150 mg tablet f/c (Zyban) CAMPRAL 4 CHANTIX 3 QL (168 per 84 CHANTIX CONTINUING MONTH 3 QL (56 per 28 BOX CHANTIX CONTINUING MONTH 3 QL (56 per 28 PAK CHANTIX STARTING MONTH 3 QL (53 per 28 BOX disulfiram (Antabuse) EVZIO 4 naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICOTROL 4 NICOTROL NS 4 QL (240 per 180 REVIA 4 SUBOXONE SUBLINGUAL FILM 12-3 MG 4 PA; QL (60 per 30 SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG 4 PA; QL (90 per 30 VIVITROL 5 ZUBSOLV SUBLINGUAL TABLET MG 3 PA; QL (120 per 30 ZUBSOLV SUBLINGUAL TABLET MG 3 PA; QL (30 per 30 ZUBSOLV SUBLINGUAL TABLET MG, MG 3 PA; QL (60 per 30 ZUBSOLV SUBLINGUAL TABLET MG 3 PA; QL (90 per 30 ZYBAN 4 introduction pages of this ocument 27

28 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL 4 QL (180 per 30 alprazolam oral tablet (Xanax) ; QL (90 per 30 (Xanax XR) ; QL (90 per 30 (Xanax XR) ; QL (60 per 30 alprazolam oral tablet extended release 24 hr 0.5 mg alprazolam oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating (Alprazolam) ; QL (90 per 30 ATIVAN INJECTION 4 QL (2 per 30 ATIVAN ORAL 4 QL (90 per 30 chlordiazepoxide hcl (Chlordiazepoxide HCl) ; QL (120 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) ; QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) ; QL (300 per 30 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) ; QL (90 per 30 clonazepam oral tablet,disintegrating 2 mg (Clonazepam) ; QL (300 per 30 clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab) ; QL (120 per 30 clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg (Tranxene T-Tab) ; QL (60 per 30 DIASTAT 4 DIASTAT ACUDIAL 4 diazepam injection (Diazepam) ; QL (10 per 28 diazepam intensol (Diazepam) ; QL (1200 per 30 diazepam oral solution (Diazepam) ; QL (1200 per 30 28

29 diazepam oral tablet (Valium) ; QL (120 per 30 diazepam rectal (Diastat Acudial) DORAL 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 estazolam oral tablet 1 mg (Estazolam) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (60 per 30 estazolam oral tablet 2 mg (Estazolam) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (30 per 30 29

30 flurazepam oral capsule 15 mg (Flurazepam HCl) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (60 per 30 flurazepam oral capsule 30 mg (Flurazepam HCl) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (30 per 30 HALCION ORAL TABLET 0.25 MG 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 KLONOPIN ORAL TABLET 0.5 MG, 4 QL (90 per 30 1 MG KLONOPIN ORAL TABLET 2 MG 4 QL (300 per 30 lorazepam oral solution (Ativan) ; QL (150 per 30 lorazepam injection solution (Ativan) ; QL (2 per 30 lorazepam injection syringe (Ativan) ; QL (2 per 30 lorazepam oral tablet (Ativan) ; QL (90 per 30 midazolam (pf) injection (Midazolam HCl/PF) ; QL (2 per 30 30

31 midazolam (pf) injection syringe 2 mg/2 (Midazolam HCl/PF) ; QL (2 per 30 ml (1 mg/ml) midazolam oral syrup 2 mg/ml (Midazolam HCl) ; QL (10 per 30 ONFI ORAL SUSPENSION 4 PA NSO; QL (480 per 30 ONFI ORAL TABLET 10 MG, 20 MG 4 PA NSO; QL (60 per 30 oxazepam (Oxazepam) ; QL (120 per 30 quazepam (Doral) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (30 per 30 RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 RESTORIL ORAL CAPSULE 7.5 MG 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 31

32 temazepam oral capsule 15 mg, 22.5 mg, 30 mg (Restoril) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (30 per 30 temazepam oral capsule 7.5 mg (Restoril) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (120 per 30 TRANXENE T-TAB ORAL TABLET 4 QL (120 per MG TRANXENE T-TAB ORAL TABLET 4 QL (60 per MG, 7.5 MG triazolam oral tablet mg (Halcion) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (120 per 30 32

33 triazolam oral tablet 0.25 mg (Halcion) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (60 per 30 VALIUM 4 QL (120 per 30 XANAX 4 QL (90 per 30 XANAX XR ORAL TABLET 4 QL (90 per 30 EXTENDED RELEASE 24 HR 0.5 MG XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG 4 QL (60 per 30 Antibacterials Aminoglycosides amikacin (Amikacin Sulfate) BETHKIS 5 PA BvD gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, piggyback Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI 5 PA BvD TOBI PODHALER INHALATION 5 QL (224 per 28 tobramycin in % nacl (Tobi) 5 PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodium Chloride) tobramycin sulfate injection solution (Nebcin) 33

34 Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) CLEOCIN IN 5 % DEXTROSE 4 clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) CLINDAMYCIN PHOSPHATE 4 INJECTION SOLUTION 150 MG/ML clindamycin phosphate intravenous (Cleocin Phosphate) solution CLINDAMYCIN PHOSPHATE 4 ORAL CAPSULE 150 MG, 300 MG, 75 MG CLINDAMYCIN PHOSPHATE 4 ORAL RECON SOLN 75 MG/5 ML colistin (colistimethate na) (Coly-Mycin M Parenteral) COLY-MYCIN M PARENTERAL 4 CUBICIN 5 DALVANCE 5 FURADANTIN HIPREX 4 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (2400 per 30 LINCOCIN 4 linezolid (Zyvox) 5 34

35 MACROBID MACRODANTIN 4 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 PA-HRM; (High Risk methenamine hippurate (Hiprex) 2 Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 GC methenamine mandelate oral tablet 1 (Methenamine gram Mandelate) MONUROL 4 nitrofurantoin macrocrystal oral capsule 100 mg (Macrodantin/Macrobi d) 2 PA-HRM; GC; QL (120 per 30 nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobi d) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 35

36 nitrofurantoin monohyd/m-cryst nitrofurantoin oral (Macrobid) (Furadantin) 2 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 PA-HRM; (High Risk ORBACTIV 5 Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (2400 per 30 polymyxin b sulfate (Polymyxin B Sulfate) PRIMSOL 4 SIVEXTRO 5 SYNERCID 5 trimethoprim (Trimethoprim) VANCOCIN 5 vancomycin in d5w intravenous (Vancomycin piggyback HCl/D5W) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) 5 VIBATIV INTRAVENOUS RECON 4 SOLN XIFAXAN ORAL TABLET 200 MG 5 PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 5 ST; QL (60 per 30 36

37 ZYVOX INTRAVENOUS 5 PARENTERAL SOLUTION ZYVOX ORAL 5 Cephalosporins AVYCAZ 5 CEDAX 4 cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 (Cefaclor) hr cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin Sodium) piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln (Ancef) cefazolin injection recon soln 100 gram, (Cefazolin Sodium) 300 g cefazolin intravenous (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % 4 CEFEPIME IN 4 DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefixime (Suprax) cefotaxime (Claforan) cefotetan (Cefotetan Disodium) cefotetan in dextrose, iso-osm (Cefotetan Disod/Dextrose, Iso) cefoxitin (Mefoxin) 37

38 cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime (Fortaz) CEFTAZIDIME IN D5W 4 ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten (Cedax) CEFTIN ORAL SUSPENSION FOR 4 RECONSTITUTION CEFTIN ORAL TABLET 250 MG, MG ceftriaxone in dextrose,iso-os intravenous (Ceftriaxone piggyback 1 gram/50 ml Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln 1 (Ceftriaxone gram Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM CEFUROXIME AXETIL ORAL 4 SUSPENSION FOR RECONSTITUTION 125 MG/5 ML cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln (Zinacef) 1.5 gram, 750 mg cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) 1 GC cephalexin oral suspension for reconstitution (Cephalexin) 1 GC 38

39 cephalexin oral tablet (Cephalexin) 1 GC CLAFORAN INJECTION 4 CLAFORAN INTRAVENOUS 4 RECON SOLN 2 GRAM FORTAZ 4 KEFLEX ORAL CAPSULE 4 MAXIPIME 4 MEFOXIN IN DEXTROSE 4 (ISO-OSM) ROCEPHIN INJECTION RECON 4 SOLN 500 MG SPECTRACEF ORAL TABLET MG SUPRAX 4 TEFLARO 4 ZERBAXA 5 ZINACEF IN STERILE WATER 4 ZINACEF INJECTION 4 ZINACEF INTRAVENOUS RECON SOLN 7.5 GRAM, 750 MG 4 Macrolides azithromycin (Zithromax) BIAXIN ORAL SUSPENSION FOR 4 RECONSTITUTION 250 MG/5 ML BIAXIN ORAL TABLET 4 BIAXIN XL 4 clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended (Biaxin XL) release 24 hr DIFICID 5 QL (20 per 10 ERYPED ERYPED ERYTHROCIN 4 39